Please complete all fields on this page to register on the EDI Services Website.

(Red * indicates a required field.)


 
Are you registering as: Provider  Clearinghouse/Billing Agency *
First Name: *
Last Name: *
Job Title: *
Company Name: *
E-mail Address: *
Confirm E-mail Address: *
Phone Number: *   Ext: 
User ID: *
Password: *

Your password must be at least eight characters in length, cannot contain your UserID and must use three of the following:

  • At least 1 uppercase letter
  • At least 1 lowercase letter
  • At least 1 number
  • At least 1 special character (!@#$%_&*)
Confirm Password:*

Select a secret question from the drop-down list below, and enter your answer in the space provided.  This secret question and answer will be used if you forget your log-in ID or password.

 
Choose a Secret Question: *
Answer to Secret Question: *
Retype Answer To Secret Question:*

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